Type 2 diabetes: what's next after metformin?

With a range of blood glucose-lowering medicines on the market, it can be hard to decide what to prescribe for patients needing more than metformin. 

 

For consumers, check out
 Medicines and type 2 diabetes

Type 2 diabetes: what's next after metformin?

Key points

  • Adherence is a critical issue to address in patients who are prescribed metformin.
  • Sulfonylureas are still recommended as a standard initial option for addition to metformin.
  • Treatment algorithms reflect the complexity of treatment decisions but offer consistent guidance on a stepped/progressive approach to blood glucose control.
 

Clinical e-Audit for GPs – Type 2 diabetes and CVD: managing the risk

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Improve health outcomes for your patients with both type 2 diabetes and cardiovascular disease (CVD) by familiarising yourself with the latest CV outcome data and increasing your confidence to navigate management choices for the condition.

This Clinical e-Audit requires data to be submitted for only SEVEN (7) patients.

Start now

This program is funded by Boehringer Ingelheim Pty Limited and Eli Lilly Australia Pty Limited and managed through VentureWise, a wholly owned commercial subsidiary of NPS MedicineWise. The program has been designed, developed and implemented by NPS MedicineWise with complete independence and editorial control and is based on best practice guidelines. 

 

Webinar: CV risk in patients with type 2 diabetes and CVD: Getting to the heart of diabetes

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Listen to our multidisciplinary panel of experts discuss the prevention of CV events in patients with both type 2 diabetes and CVD. Discussion covers:

  • Evidence-based strategies to reduce CV risk for patients with diabetes and CVD
  • Advice on how to individualise choice of blood glucose-lowering agents
  • The latest Australian blood glucose treatment algorithm for type 2 diabetes
  • An update on the latest CV outcome trial data and how this impacts your practice  

Listen to the webinar on demand

This program was funded by Boehringer Ingelheim Pty Limited and Eli Lilly Australia Pty Limited and managed through VentureWise, a wholly owned commercial subsidiary of NPS MedicineWise. The program has been designed, developed and implemented by NPS MedicineWise with complete independence and editorial control and is based on best practice guidelines.

  • Evidence-based strategies to reduce CV risk for patients with diabetes and CVD
  • Advice on how to individualise choice of blood glucose-lowering agents
  • The latest Australian blood glucose treatment algorithm for type 2 diabetes
  • An update on the latest CV outcome trial data and how this impacts your practice  
 

Australian Prescriber: Second steps in managing type 2 diabetes

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Dr Carolyn Petersons
Aust Prescr 2018;41:141-4

Metformin is still first choice for type 2 diabetes, but what comes next? In the October 2018 issue of Australian Prescriber, Dr Carolyn J Petersons sorts out the second steps in managing type 2 diabetes.

Read the full article

Listen to the podcast.

Episode 36 – Dhineli Perera interviews Dr Carolyn Petersons about the second- and third-line drugs for type 2 diabetes. After metformin, what comes next?

 

Empagliflozin indications extended


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Empagliflozin is now TGA-approved for reducing cardiovascular deaths in patients with type 2 diabetes with established cardiovascular disease.

What is the evidence, and what does this mean in clinical practice?

Read the full article. 

 

NPS RADAR: Insulin glargine 300 IU/mL solution (Toujeo) for diabetes mellitus

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Insulin glargine 300 IU/mL (Gla-300) solution is another option for adults with type 1 or type 2 diabetes requiring a long-acting basal insulin. Gla-300 is a concentrated formulation of the PBS-listed Gla-100.

Read more about this long-acting insulin.

 

MedicineWise News: Type 2 diabetes – when metformin is not enough


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Sulfonylureas are the usual add-on treatment when metformin is no longer sufficient, but are they the best? Review the evidence on efficacy, safety and outcomes for second-line type 2 diabetes treatments. 

Find out about what comes after metformin.

 

NPS RADAR: Pharmacological therapies in Australia for type 2 diabetes


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Guidelines recommend a stepwise approach to management of type 2 diabetes mellitus.

Find out more about the options recommended in Australia.

 

Metabolic syndrome and diabetes: how much blame does sugar deserve? 


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An increasing number of journal articles and media stories are highlighting the potential role of dietary sugar, and particularly added fructose, as a major contributor to ill health, from cardiovascular disease to type 2 diabetes to metabolic syndrome.

Find out more about the evidence for the role of sugar in these conditions.

 

Australian Prescriber: Encouraging adherence to long‑term medication


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Tim Usherwood
Aust Prescr 2017;40:147-501

Patients should be asked about adherence at every consultation.

Read the full article here

Learn more about:

  • using a collaborative communication style
  • using the patient’s own expressions and responding to their cues
  • how to normalise non-adherence
  • using open questions and more specific probes.

Listen to the podcast

Episode 6 – Encouraging adherence to long-term medication, with Prof Tim Usherwood

Dr Janine Rowse interviews Professor Tim Usherwood about the different types of medication non-adherence and his practical recommendations for better identification in the primary care setting.

  • using a collaborative communication style
  • using the patient’s own expressions and responding to their cues
  • how to normalise non-adherence
  • using open questions and more specific probes.
 

CPD options

Consolidate your knowledge about type 2 diabetes, brush up on current guidelines and practices and earn CPD points through our learning activities.

For GPs:

For your patients: Lifestyle and metformin decision aid

This decision aid is for people who have been diagnosed with type 2 diabetes, have tried lifestyle changes and are deciding whether to continue with lifestyle changes alone or start metformin. It can be used before a consultation to learn about the options, during the consultation to discuss and jointly decide on an option or at another time with discussion at a follow-up consultation.

Lifestyle and metformin decision aid

Date published : 7 July 2016

 

Principles of pharmacological management of type 2 diabetes

The choice, order and combination of medicines are based on evidence, risk of adverse effects and patient choice.1

  • Metformin is the drug of first choice for people with type 2 diabetes who have inadequate glycaemic control after 3 months of making lifestyle changes. Sulfonylurea may be used if metformin cannot be tolerated.1-4
  • Only add another medicine if target blood glucose levels are not achieved after titrating metformin (or a sulfonylurea) to the highest tolerated dose.1,2
  • Always check and address other factors that may interfere with control before adding a second or third glucose-lowering medicine e.g. poor self-management of diet and fitness, nonadherence to medicine, medicines that increase blood glucose levels such as steroids.2
  • The preferred medicine to add as second-line therapy is a sulfonylurea, as it is the most cost effective and is supported by decades of clinical experience.1,2,4 Alternative approaches include introducing one other oral glucose-lowering medicine (thiazolidinedione, DPP4 inhibitor, acarbose, SGLT2 inhibitor) or if the patient is willing to self-inject, insulin or a GLP1 agonist.1 Consider this in addition to lifestyle measures, adherence to medicines and dose titration.1,2
  • Insulin is the preferred drug for people with inadequate glycaemic control despite taking maximally tolerated doses of oral glucose-lowering agents.1,2 Anticipate and proactively address hesitation to beginning insulin therapy.1,2

 
 

Evidence summary on type 2 diabetes

The prevalence of diabetes is increasing, with an estimated 5% of Australians currently diagnosed with the chronic disease.1

Diabetes impacts quality of life, life expectancy and morbidity as a result of microvascular complications (retinopathy, nephropathy and neuropathy) and the increased risk of macrovascular complications (ischaemic vascular disease, stroke and peripheral vascular disease).2

Good glycaemic control reduces the development or progression of diabetes complications and can improve quality of life.2

About 60% of people with type 2 diabetes have cardiovascular disease and around 65% of all cardiovascular disease deaths in Australia occur in people with diabetes.3

Addressing lifestyle factors, blood pressure and blood lipids are just as essential, as they seem even more effective than glycaemic control in reducing the risk of cardiovascular complications.4

Reducing risk of cardiovascular events in people with type 2 diabetes requires concurrent management of lifestyle factors, blood pressure, lipids and blood glucose.1